Deficiencies found in post-birth care of new mother

Source: 1News

The Counties Manukau District Health Board (CMDHB) has been found to have "systemic deficiencies" by a review after a patient with vaginal fistulas was left untreated and undiagnosed.

A person in a hospital bed (file picture).

A review from Health and Disability Deputy Commissioner Rose Wall said the CMDHB patient experienced fluid leaking from her vagina and a breast infection after a rare Caesarean section complication in 2019.

The woman went to the hospital twice after being discharged the first time but was told her symptoms were due to expected vaginal discharge after childbirth. She was discharged to the care of her community midwife.

The woman’s GP referred her to a gynaecologist a month later where a CT scan showed a fistula between her ureter and vagina.

Wall has now made a raft of recommendations and says CMDHB was found in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights.

In her report, Wall said she was worried about the care provided by CMDHB. She said it didn’t undertake adequate assessment and investigation of the woman’s symptoms, discharging her without appropriate outpatient follow-up in place, and giving her a diagnosis that was not consistent with her symptoms.

"I am critical of the care provided to the woman over two hospital admissions, and the extended time it took CMDHB to reach the correct diagnosis for her presenting symptoms, particularly as they persisted over an extended period without resolution.

"These deficiencies demonstrate missed opportunities to investigate the cause of the woman’s symptoms fully or place her on the correct diagnostic pathway,” Wall said.

Wall recommended CMDHB give the woman with a written apology and implement a clinical pathway for future suspected vaginal fistulas cases.

She said this is to guide clinicians on the appropriate tests and imaging to request, and examinations to undertake.